Gastroenterology Coding Alert

Don’t forget to catch non-mutually exclusive bundles with fluoroscopy too.

As you begin using the newly introduced codes for optical endomicroscopy, pay extra attention to version 19.0 of the Correct Coding Initiative (CCI) edits – the focus of these edits is on what codes you can report when your gastroenterologist performs endomicroscopy with other endoscopic procedures.

Note That 43252 Bundles Same Session Esophagoscopy Procedures

CCI 19.0 includes non-mutually exclusive edits for upper EGD with optical endomicroscopy (43252, Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with optical endomicroscopy) procedure when performed with several other gastrointestinal endoscopy procedures. Coding for 43252 overrides the following codes when a physician performs both procedures in the same session:

43200 — Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]

43201 — …with directed submucosal injection[s]

43202 — …with biopsy, single or multiple

43204 — …with injection sclerosis of esophageal varices

43205 — …with band ligation of esophageal varices

43206 — …with optical endomicroscopy

43215 — …with removal of foreign body

43216 — …with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery

43217 — …with removal of tumor[s], polyp[s], or other lesion[s] by snare technique

43219 — …with insertion of plastic tube or stent

43220 — …with balloon dilation [less than 30 mm diameter]

43226 — …with insertion of guide wire followed by dilation over guide wire

43227 — …with control of bleeding

43228 — …with ablation of tumor[s], polyp[s], or other lesion[s], not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique

43231 — …with endoscopic ultrasound examination

43232 — …with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy[s]

43235 — Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic…

43236 — …with directed submucosal injection[s]

43237 — …with endoscopic ultrasound examination limited to the esophagus

43239 — …with biopsy, single or multiple

43255 — …with control of bleeding, any method

44360 — Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; diagnostic…

44376 — …including ileum…

Don’t Report 43206 Separately With These Endoscopy Procedures

If your gastroenterologist performs optical endomicroscopy with esophagoscopy and also performs other EGD procedures, you cannot report the endomicroscopy procedure using 43206, as CCI includes 43206 into the more comprehensive EGD procedure. "If optical endomicroscopy is performed during a more comprehensive EGD procedure, then the correct code would be 43252," says Michael Weinstein, MD, Gastroenterologist at Capital Digestive Care in Washington, D.C., and former representative of the AMA’s CPT^® Advisory Panel.

Some of the codes that override reporting 43206 separately when performed in the same session include:

43235

43236

43237

43238 — Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy[s], esophagus [includes endoscopic ultrasound examination limited to the esophagus]

43239

43240 — …with transmural drainage of pseudocyst

43241 — …with transendoscopic intraluminal tube or catheter placement

43242 — …with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy[s] [includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum and/or jejunum as appropriate]

43243 — …with injection sclerosis of esophageal and/or gastric varices

43244 — …with band ligation of esophageal and/or gastric varices

43245 — …with dilation of gastric outlet for obstruction

43246 — …with directed placement of percutaneous gastrostomy tube

43247 — …with removal of foreign body

43248 — …with insertion of guide wire followed by dilation of esophagus over guide wire

43249 — …with balloon dilation of esophagus…

43250 — …with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery

43251 — …with removal of tumor[s], polyp[s], or other lesion[s] by snare technique

43255 — …with control of bleeding, any method

43256 — …with transendoscopic stent placement…

43257 — …with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease

43258 — …with ablation of tumor[s], polyp[s], or other lesion[s], not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique

43259 — …with endoscopic ultrasound examination, including the esophagus, stomach, and either the duodenum and/or jejunum as appropriate

Know When to Report Fluoroscopy Procedures Separately

CCI 19.0 specifies that you cannot report separately any fluoroscopy or ultrasound guidance that is performed along with optical endomicroscopy (43206 or 43252). While the bundling with 76975 and 76998 carry the modifier indicator ‘0’ indicating that these codes cannot be reported with endomicroscopy codes at all times, the other fluoroscopy edits carry the indicator ‘1’ which means that you can report such procedures separately using appropriate modifiers.

The following codes cannot be used with 43206 or 43252:

76000 — Fluoroscopy [separate procedure], up to 1 hour physician or other qualified health care professional time…

76001 — Fluoroscopy, physician or other qualified health care professional time more than 1 hour…

76942 — Ultrasonic guidance for needle placement…

76975 — Gastrointestinal endoscopic ultrasound, supervision and interpretation

76998 — Ultrasonic guidance, intraoperative

77001 — Fluoroscopic guidance for central venous access device placement, replacement [catheter only or complete], or removal…

77002 — Fluoroscopic guidance for needle placement…

Learn more: CCI 19.0 overrides reporting skin closure codes with optical endomicroscopy. For the complete set of the version 19.0 of the CCI edits, visit www.cms.gov/NationalCorrectCodInitEd — or search for bundles affecting individual codes by using the CCI edits checker at https://www.aapc.com/codes/.